New Nurse Residency - An Evidence Based Approach

Transcription

1 UNF Digital Commons UNF Theses and Dissertations Student Scholarship 2009 New Nurse Residency - An Evidence Based Approach Alice M. Nied University of North Florida Suggested Citation Nied, Alice M., "New Nurse Residency - An Evidence Based Approach" (2009). UNF Theses and Dissertations. Paper This Doctoral Project is brought to you for free and open access by the Student Scholarship at UNF Digital Commons. It has been accepted for inclusion in UNF Theses and Dissertations by an authorized administrator of UNF Digital Commons. For more information, please contact j.t.bowen@unf.edu All Rights Reserved

2 . New Nurse Residency-an Evidence Based Approach by Alice M. Nied A project submitted to the School of Nursing in partial fulfillment of the requirements for the degree of Doctor of Nursing Practice UNIVERSITY OF NORTH FLORIDA BROOKS COLLEGE OF HEALTH December, 2009

3 Signature deleted Signature deleted Signature deleted Signature deleted Signature deleted Signature deleted

4 iii Dedication To my husband, Tom when we began this journey many years ago, when I was a diploma prepared RN, content with small dreams. It was your love, support, and belief in me that made me believe I could dream and achieve bigger dreams. To Dr. Kathy Bloom of the University of North Florida you supported my efforts when I was ready to walk away; thank you for your guidance, assistance, but most of all, for your encouragement. It is greatly appreciated. To the other nursing faculty and administrators at UNF, you began as my colleagues and ended as my faculty. I would not have entered your program if I had not had the utmost respect for each and every one of you you are the best! To my parents, Walter and Lucille Fiedler I wish you were here to see me reach this goal. You were the ones who told me that education was a way out, a way to improve my life, and once achieved, something that no one could ever take away from me. I am happy to say that I have reached the point in my life where I can admit that you were right!

5 iv Table of Contents Certificate of Approval... ii Dedication... iii Table of Contents... iv List of Tables... vi Abstract... vii Chapter 1: Introduction... 1 Purpose... 3 Chapter 2: Review of Literature... 4 Nursing Education and Nursing Practice... 4 Nursing Education... 4 Nursing Practice... 5 Disconnect Regarding the Competencies of New RNs... 7 State of the Science: New Nurse Assimilation into Practice...8 Search Strategy...8 Evidence Regarding Competence of New RNs... 9 Evidence Regarding Nurse Residency Programs...10 Preceptors Mentors Curriculum Length of Residency Programs Cost of Residency Programs Summary Chapter 3: Methodology Design Sample and Setting Procedures Selection of Mentors Selection of Preceptors Matching New RNs with Mentors and Preceptors Preceptor/Mentor Orientation 21 Survey Tool 21

6 v Curriculum Classroom Clinical Data Collection Feasibility Protection of Human Subjects Chapter 4: Results 25 Sample...25 Reliability of the Survey Instrument...26 Pre-residency Survey Results The Residency...28 Post-residency Survey Results...31 Pre- Post- Comparisons.31 Residents Evaluation of the Experience...33 Preceptors and Mentor s Evaluation of the Residency...35 Chapter 5: Discussion...36 Perceived Competencies of the Residents...36 The Residents...36 The Preceptors...37 The Mentors...37 Comparisons...37 Limitations...40 Implications for Future Research...41 Implications for Nursing Practice and Administration...41 Summary 43 Appendices A: Critical Analysis Table of Self-Perceptions of New RN Competence B: Critical Analysis Table for Nurse Residency Programs C: Preceptor/Mentor (P/M) Training D: New Nurse Survey E: New Nurse Residency Teaching Guide References...55 Vita...60

7 vi List of Tables Table 4.1: Sample Characteristics...26 Table 4.2: Pre-Residency Perceived Competencies of New RNs by the Residents, Preceptors and Mentors...27 Table 4.3: Post-Residency Perceived Competencies of New RNs by the Residents, Preceptors and Mentors...32 Table 4.4: Paired Differences in Total Score Averages on Competency Scale...34

8 vii Abstract Nurse educators believe that their graduates are well-prepared for entry level positions in nursing. In the acute healthcare setting, new graduates are placed on virtually every type of nursing unit, including critical care. Employers have developed formal orientations to familiarize new graduate nurses new with the institution and its policies and procedures and to teach the things employers believe new RNs need to know but do not, either because they were never taught the material or they have not retained it. The purposes of this project were to (a) examine the evidence relative to a disconnect between nursing education and nursing practice, (b) design a formal residency program for new graduates based on the evidence, and (c) implement and evaluate the residency program. Based on the evidence, a 16-week new nurse residency was developed in which Residents were each assigned both a Preceptor and Mentor to assist their progress. Weekly educational offerings were targeted at specific competency deficits identified by Residents, Preceptors and Mentors at the beginning of the residency program. Seven out of the original 10 Residents completed the Residency. Pre-residency, the Residents were very confident of their clinical skills and abilities and this was unchanged post-residency. The Preceptors and Mentors were much less confident of the clinical skills and abilities of the Residents pre-residency. Post-residency, the confidence level of the Preceptors and Mentors was improved, but significantly so only for the Mentors. It is imperative that nursing administrators be aware of the discrepancy between the confidence new nurses have in their own skills and the perceptions of the nurses who

9 viii work side by side with them on a daily basis. Residencies for new graduate nurses are costly. Nursing administrators must make the determination if the benefits outweigh the costs. They may find the results of not having a residency are far more costly.

10 Chapter 1: Introduction The mission statements of all health care organizations are related to the restoration of optimal health to their clients. As acuity levels in acute care facilities rise, a skilled and knowledgeable staff of registered nurses (RNs) is essential to making this mission a reality. The current and predicted future nursing shortage has been well-documented in all areas of nursing (Altier & Krsek, 2006; Cavanaugh & Huse, 2004; Duchscher & Myrick, 2008). The nursing shortage is a global crisis. It is estimated that by 2020 the supply will be 20% below the demand (Cavanaugh & Huse, 2004) or an estimated RN shortage of 400,000 in the United States (Altier & Krsek, 2006). The shortage will continue to escalate since, as Herdrich and Lindsay (2006) report, the age of the average American RN is increasing and seasoned nurses are retiring, becoming the recipients of care instead of the providers of care. The logical way to combat this problem is with new graduate RNs. The call for additional nursing graduates has resulted in baccalaureate nursing programs increasing enrollments nationwide by 5% from 2005 to 2006 and 4.98% from 2006 to 2007 (American Association of Colleges of Nursing [AACN], 2007). There was a rise again in 2008 by an additional 2.2% (AACN, 2009). Associate degree programs report similar increases in enrollments (National Organization for Associate Degree Nursing [NOADN], 2007). This increases the numbers of new nurses available. However, turnover rates of new RNs in the first year after graduation range from 29.5%

11 2 (Halfer, 2007) to 61% (Pine & Tart, 2007). In addition, 25% of these nurses have had two or more positions in their first six to eight months of employment (Halfer, 2007). The question of why new graduate nurses leave one or more employers in their first year of professional nursing practice is an important one. Duchscher and Myrick (2008) found five factors that contribute to new graduate nurses leaving a job: (a) abuse from seasoned nurses who are unhappy and worn out, (b) loss of self-confidence and selfconcept on the part of the new graduate nurses, (c) poor staffing patterns in the acute setting, (d) an institutional culture that supports the status quo preventing autonomous practice, and (e) a lack of transitional support for the new graduate nurse. The costs associated with nursing turnover are a significant drain on the organization. The cost to hire one new graduate RN is approximately $41,624 (Halfer, 2007). It costs the organization between $35,000 and $49,000 each time a nurse with less than one year tenure leaves the organization (Beecroft, Kunzman, & Krozek, 2001; Lindsey & Kleiner, 2005). This makes it imperative for the welfare of our hospitalized clients and the fiscal health of hospital organizations to enhance the skills and abilities of new RN hires and to insure that they make a commitment to remain with the organization for many years. The increase in the numbers of new nurses entering practice has resulted in attention being focused on ways to successfully transition them into their nursing careers. Traditional orientation programs allow employers to complete checklists of organizational policies and procedures but they do not promote professionalism, stress the importance of lifelong learning or teach strategies to decrease the stress level of the new nurse (Herdrich & Lindsay, 2006).

12 3 In addition, concerns about the graduate nurses clinical competence need to be addressed. It is a widely held belief that new RNs do not come to the workplace ready to take the place of an experienced nurse (Diede, McNish, & Coose, 2000). One strategy that has been successfully utilized to bring these new RNs to the desired level of clinical competence is through a structured new nurse residency. The residency is in addition to the traditional orientation and is focused on areas not mastered in the new nurses education. These areas include improving critical thinking and clinical judgment such as time management skills, prioritization, delegation, and knowing when and why they should contact the provider. Purpose The purposes of this project were to: 1. Examine the evidence relative to a disconnect between nursing education and nursing practice; 2. Design a formal residency program for new graduates based on the evidence; and 3. Implement and evaluate the outcomes of the residency program.

13 4 Chapter 2: Literature Review This chapter will begin with an overview of the complexities of nursing practice and nursing education and the apparent disconnect between the perceptions of practice and education with respect to the competencies of new nursing graduates. This will be followed by a description of search strategies used to identify the best evidence for addressing the issues related to new nursing graduates. The chapter will conclude with an evaluation and synthesis of the evidence regarding interventions that have been shown to assist the new graduate in the transition from nursing education to nursing practice. Nursing Education and Nursing Practice Nursing Education The road to becoming an RN is not uniform. There remain three different paths to this goal; the diploma, the associate degree, and the baccalaureate degree (Aranda, 2007). The first nursing programs were hospital-based diploma programs. These programs were developed in the 19 th century and continued until the 1970 s. A few still remain in operation, the majority of them in Pennsylvania. These programs were administered by the sponsoring hospital who often housed the student nurses in dormitories on the hospital grounds. The programs were three calendar years in length, had a strong clinical focus and few or no college credits as part of the curriculum. (Woolley, 2004) The nursing shortage following World War II prompted the development of the associate degree (AD) in nursing in 1954 (Newton, 1964). Associate Degree education was the result of the doctoral dissertation of Mildred Montag and was intended to replace

14 5 the nurses who left the profession to become wives and mothers after World War II. The program was to be completed in two years and was designed for non-traditional students who would bring maturity and life experience to their nursing education. Associate degree programs are generally housed in community or technical colleges and award college credits that can be transferred into senior institutions for baccalaureate credit (Woolley, 2004). Baccalaureate nursing education began as postgraduate education certificate programs for nurses who wished to teach, become administrators, and public health. Generic baccalaureate nursing education began with the Yale University nursing program in 1923 and was established to change the paradigm from the needs of the hospital to the educational needs of the student. The baccalaureate program provides the student with a foundation in liberal arts that was missing in the diploma and AD programs. (Woolley, 2004) Nursing Practice New nurses begin their first professional nursing position in a variety of practice settings, including general medical-surgical units, specialty units such as pediatrics, obstetrics and mental health as well as the fast-paced, high acuity areas of critical care units, emergency rooms, labor and delivery and operating rooms. Nursing administrators are vocal in their dissatisfaction with graduate nurses. Nurses in nursing specialties are even more unhappy with the clinical skills and abilities of new graduate nurses. For example, Jones and Sheridan (1999) believe the weakness in graduate nurses performance in pediatrics is due to lack of exposure to the area and the isolation of

15 6 education from nursing practice. Beecroft et al. (2001) agree, but add that new graduates fear working in a dedicated pediatric hospital where the acuity is so high. In the area of critical care, Cavanaugh and Huse (2004) and Messmer, Jones, and Taylor (2004) describe the difficulty nurses experience when attempting to transfer classroom knowledge to the bedside. The authors report that in periods of less shortage, RNs were required to have one to two years experience in the medical/surgical area prior to working in critical care, but the current shortage has allowed new graduate RNs to be hired directly into critical care. Novice nurses struggle with the pace of an intensive care setting and the need to make critical decisions quickly. Orsini (2005) reported on an orthopedic unit with an attrition rate of 22.6%. This unit was able to decrease the attrition rate to 7.7% with a one year retention rate of 100% after the implementation of a unit-specific residency. After the residency was established, the unit also received two organization-wide awards; one for Best Team Spirit and Most Improved Customer Satisfaction. Other units in the hospital have now adopted this model in hopes to replicate the orthopedic unit s success. Truman (2004) reported on an emergency department where the nurses made the conscious decision to not eat their young but to put their efforts into teaching the new nurses. New nurses reported their confidence in their clinical skills increased. Knowing that the staff nurses would help them is key to their continued clinical growth (Etheridge, 2007). The new nurses intent to remain in a position is influenced by the unit culture, whether they felt they belonged and were wanted on the unit (Altier & Krsek, 2006).

16 7 Disconnect Regarding the Competencies of New RNs Employers express concerns about the readiness of new nurses to assume the role of the professional nurse in clinical practice (Anders, Douglas, & Harrigan, 1995; Beecroft et al., 2001; Conger, 1999; Goode & Williams, 2004; Lindsey & Kleiner, 2005; Santucci, 2004). These concerns are based on the complaints voiced by the colleagues of the new RNs and center around the following areas; (a) a lack of knowledge of appropriate delegation, (b) inability to perform physical assessment or interpret lab data, poor prioritization and time management skills, (c) ineffective response to emergencies or the (d) ability to determine that an emergency exists (Goode & Williams, 2004; Owens et al., 2001); and (e) critical thinking (Halfer, 2007; Turner, 2005). Nurse educators have a somewhat different perspective. When asked, 80% of nurse educators responded that their graduates meet their competency expectations at the time of graduation, while only 47.5% of the surveyed hospital directors of nursing agreed (Anders et al., 1995). Allmark (1995) reiterated the existing gap between the theory and practice of nursing. AD nursing faculty believe their curricula meets the needs of nursing practice and speaks of the need to maintain the relevance of their curricula in order to meet the changing needs of the nursing profession (Diede et al., 2000). How to effectively teach or improve the critical thinking of student nurses is an evolving pedagogy, and effective means of evaluating a change in the critical thinking of nursing students are lacking. In a review of the evidence regarding critical thinking published between 1975 and 2002, Staib (2003) identified several strategies used by nurse educators to enhance critical thinking: (a) computer-assisted instruction (CAI), (b) case studies, (c) group learning strategies focused on the process of thinking, (d) critical

17 8 thinking vignettes designed to teach critical thinking in a simulated clinical situation, and (e) role playing and the use of imagery. This review of the evidence revealed no consistent evidence between the years that any strategies employed by nurse educators increased the level of critical thinking of nursing students (Staib, 2003). More recently, Horan (2009) reported on the use of human patient simulators to enhance the critical thinking of a group of nursing students. Although the students were more enthusiastic, their critical thinking ability was no more improved than the critical thinking of a group of students who studied critical thinking in a classroom setting. State of the Science: New Nurse Assimilation into Practice Attempts have been made to decrease this disconnect between education and practice. An extensive literature search was done to identify and synthesize the evidence related to facilitating assimilation of the new nurse into the practice setting. Search Strategy The Cumulative Index of Nursing and Allied Health (CINAHL), PubMed, the Cochrane Library, and Medline were all utilized to locate evidence for this project. All of the following terms, in various combinations were used to search the listed databases; nurses, new nurses, new RNs, new graduate nurses, competence, perception, clinical skills, clinical judgment, improving, technical skills, abilities, job performance, job expectations, critical thinking, acquisition of critical thinking skills, decision making, teaching, technical skills, attrition, turnover, professionalism, reality shock, simulation and skill acquisition, delegation, curricula, impact of curricula on learning, professional commitment, residency, orientation, preceptors, and mentors. The search covered the years 1990 to A total of three studies were found that examined the perception of

18 9 the new RNs own competence (see Appendix A). A total of seven studies were found examining nurse residency programs (see Appendix B). Evidence Regarding Competence of New RNs New nurses begin their professional career possessing an eagerness to learn, wanting to feel competent in their practice, and feeling impatient at their own learning curve (Graham, Hall, & Sigurdson, 2008; Hodges, Keeley, & Troyan, 2008; Oerrman & Moffitt-Wolf, 1997). New nurses also possess a strong theory-base for practice (Graham et al., 2008), but are aware of their limited clinical experiences (Heslop, McIntyre, & Ives, 2001). They often report feeling overwhelmed at their work load (Oerman & Moffitt-Wolf, 1997). The new nurses seek the approval of the experienced nurses with whom they work (Etheridge, 2007) and seek employment at hospitals where there are opportunities for guidance and support (Heslop et al., 2001). The concerns of nurses in clinical practice and administration are clear regarding the shortcomings of new RNs. At the University of Pittsburgh Medical Center, only 43% of the nurses surveyed felt that the new RNs were able to practice safely (Keller, Meekins, & Summers, 2006). Their concerns included the ability of the new graduate to resolve conflict, problem solve, use critical thinking, delegate, and interact with physicians. This concern is mirrored by Pine and Tart (2007) who found clinical judgment, decision making, leadership, professional commitment, and a lack of evidence based practice in new RNs. Weakness in critical thinking, clinical judgment, supervision of others or ineffective delegation, response to emergencies, inability to recognize abnormal lab or other diagnostics, and performance of psychomotor skills have been documented in multiple studies (Altier & Krsek, 2006; Beecroft et al., 2001; Goode &

19 10 Williams, 2004; Herdrich & Lindsay, 2006). Other areas of concern voiced by seasoned nurses concerning new graduates were the intangibles: lack of commitment to the profession, lack of confidence in professional skills (Beecroft et al., 2001), an inability to handle stress, poor problem solving skills (Herdrich & Lindsay, 2006), and subpar organizational and teamwork skills (Goode & Williams, 2004). Nurses who begin their professional nursing practice in a specialty area such as perioperative nursing have a huge learning curve (Persaud, 2008). Traditionally, new graduate nurses were barred from specialty areas, but no more. It is now the norm for graduates to go from school to specialty areas due to the current nursing shortage. These new nurses must not only make the leap from nursing education to nursing practice, they must also learn the intricacies of a nursing specialty. Evidence Regarding Nurse Residency Programs Both fiscal and job performance issues have resulted in hospitals seeking out ways to facilitate the transition of new graduate RNs into the professional role in hopes of increasing clinical competence and decreasing turnover. Formal nurse residencies are one strategy that has had positive outcomes (Altier & Krsek, 2006; Beecroft et al., 2001; Cavanaugh & Huse, 2004; Conger, 1999; Goode & Williams, 2004; Grindel & Hagerstrom, 2009; Halfer, 2007; Halfer, Graf, & Sullivan, 2008; Herdrich & Lindsay, 2006; Jones & Sheridan, 1999; Lindsey & Kleiner, 2005; Mills & Mullins, 2008; Morrell, 2005; O Brien-Pallas, Duffield, & Hayes, 2006; Oermann, 1998; Orsini, 2005; Owens, et al., 2001; Pine & Tart, 2007; Thomka, 2001; Tourangeau & Cranley, 2006; Verdejo, 2002; Wagner, 2007; Williams, Goode, Krsek, Bednarski & Lynn, 2007). The goals of the residencies are to improve critical thinking and enhance the ability of the new nurse

20 11 to perform physical assessment, interpret lab data, and determine when and why to contact the primary provider. Other goals include improving time management skills and ability to prioritize, learning how to identify and function in an emergency, improving conflict resolution skills, understanding how to safely delegate, and generally improve clinical competence. There is some variation in the components of various residencies but the common goals are to improve clinical performance, decrease attrition and eliminate the cost of replacing nurses. Common elements to successful nurse residency programs include preceptors and mentors, the curriculum itself and a positive return on investment. Because of the key role preceptors and mentors play, it is essential for them to be formally trained prior to the beginning of the residency (Altier & Krsek 2006; Beecroft et al., 2001; Cavanaugh & Huse, 2004; Goode & Williams, 2004; Halfer, 2007; Halfer, Graf, & Sullivan, 2008; Herdrich & Lindsay, 2006; Lindsey & Kleiner, 2005; Messmer, et al., 2004; Mills & Mullins, 2008; Owens et al., 2001; Persaud, 2008; Truman, 2004; Verdejo, 2002; Williams et al., 2007). Selection, training, and roles of mentors and preceptors in formal new RN residencies are critical, and the two roles should not be confused. (Altier & Krsek, 2006; Halfer, 2007; Truman, 2004; Verdejo, 2002). Preceptors. The preceptors guide the new nurse resident through the day-to-day residency experience. The role of the preceptor is to teach, support, evaluate, advocate and protect the new nurse resident (Vermont Nurses Internship Project [VNIP], 2003). In addition, preceptors model the behaviors they want to see in the new nurse resident including a positive attitude and the ability to work with different members of the interdisciplinary team to support positive patient outcomes (Godinez, Schweiger, Gruver,

21 12 & Ryan, 1999). Santucci (2004) emphasized the role of the preceptor in socialization, performance, professionalism, and job satisfaction for the new nurse resident. Preceptors are key to the success of a residency program (Spector & Li, 2007) and so care in the selection process is essential. Preceptors are generally selected following an application process during which several factors are evaluated: academic credentials, tenure at facility, clinical competence, effective interpersonal and communication skills, support of nurse manager, commitment to professional development, a willingness to precept, and a supportive attitude toward new graduates (Owens, et al., 2001; Truman, 2004). A preceptor training course including strategies for identifying learning needs, mutual goal setting, facilitation of critical thinking, and giving effective feedback is recommended (Goode & Williams, 2004). While Messmer et al. (2004) believe that preceptors should be competent or proficient nurses, but not experts, others purposefully select preceptors based on expert knowledge, rationale-based practice and commitment to mentoring staff (Cavanaugh & Huse, 2004). Preceptor training should include a discussion on the role of the preceptor, learning styles, and role modeling the professional nursing role (Owens, et al., 2001). Assessment of the skills and learning needs of others and learning to give feedback in a nonthreatening manner is emphasized (VNIP, 2003). Benefits of the new nurse residency, verbal and non-verbal communication with the new nurse resident, listening skills, and communication barriers need to be reinforced to potential preceptors. Gilge, Klose, and Birger (2007) advocate the development of an environment that supports learning. Mentors. Mentors do not have a hands-on role with the new nurse residents. The role of the mentor is to be an objective listening ear, a voice without bias, who possesses

22 13 the ability to provide insights into finding balance between work and life. New graduate nurses have found mentors provided valuable insights into how to adjust to shifting work schedules, commuting to work, the graduates fear of making mistakes, fear of not fitting into the unit culture, and coping with living in a new city (Halfer, 2007). Persaud (2008) views the role of the mentor as fostering a nurturing relationship with the new graduate nurse, assisting the new graduate nurse in becoming a professional, offering constructive feedback, and helping them work through difficult situations. Role modeling, teaching, encouraging, counseling, and being a friend are all part of the role of the mentor (Mills & Mullins (2008). Nurturing and protecting graduates are key behaviors of mentors (Orsini, 2005). Mentors also serve as sounding boards, assist in deciphering communications, and provide an objective perspective and someone to turn to in times of stress (Beecroft et al., 2006). The selection of mentors is important to meeting the goals of residency. Mentors should possess good leadership skills, a professional demeanor, a commitment to excellence, a track record of advancement, the ability to empower, respect of their peers, and patience (Persaud, 2008). As with preceptors, mentors require training. The training should include a discussion of the role of the mentor, a review of communication techniques, expected activities the mentor and new nurse resident will share, and assisting the mentor in determining a plan for the mentor-mentee relationship (Hayes & Gagan, 2005). Curriculum. The curriculum for the nurse residency varies. Owens et al., (2001) focused on the acquisition or enhancement of technical skills, as did Halfer (2007). Becoming a member of the profession, increased confidence, and decreased orientation

23 14 time was stressed by Lindsey and Kleiner (2005) and Truman (2004), while others emphasized the improvement of critical thinking skills and clinical judgment (Altier and Krsek, 2006; Herdrich and Lindsey, 2006). Pine and Tart (2007) reported the importance of decreasing stress in the new RN. Additionally, Goode and Williams (2004) stressed development of soft skills such as recognizing abnormal physical and lab results, time management, prioritization, psychomotor skills and response to emergencies. All the residency programs reviewed included the use of preceptors. The role of the preceptor in all the programs was similar that of the 1:1 clinical partner who fosters the clinical growth of the new nurse residents. Owens et al. (2001) reported that one residency program failed to assign the resident and the assigned preceptor the same schedule and this negatively impacted the residents perception of the residency. Mentors were included in many of the residencies reviewed (Altier and Krsek, 2006; Beecroft, et al., 2001; Halfer, 2007; Halfer & Graf, 2006; Truman 2004). The role of the mentor was similar in each of the residencies reviewed, that of supportive role model who made themselves available to listen and to assist the new nurse resident. Trained preceptors enhanced the experience of the residents (Altier & Krsek, 2006; Beecroft et al., 2001; Cavanaugh & Huse, 2004; Messmer et al., 2004; Owens et al., 2001; Williams et al., 2007). Owens et al., (2001) held a skills/physical assessment day to hone the technical and assessment skills of the resident. Other effective strategies included bi-weekly evaluations from the preceptor (Williams et al., 2007), utilization of a head-to-toe approach in physical assessment to assist the resident in organizing their thinking (Messmer et al., 2004), and interviews between preceptors and new nurse

24 15 residents to determine the resident s self-perceived their learning needs (Cavanaugh & Huse, 2004). Strategies employed in the weekly classroom sessions included debriefing and selfcare sessions (Beecroft et al., 2001; Truman, 2004). Other classroom activities include practice with lab/diagnostics interpretation, determination of emergent conditions and appropriate responses, priority setting, delegation, infection control, nutrition, age specific issues, communication with families, skin care, blood/blood product infusion, pharmacology, and stress management (Owens et al., 2001). Cavanaugh and Huse (2004), used classroom time to problem solve, prioritize, plan, manage time, enhance clinical judgment, and understand resource allocation. Truman (2004) reported the inclusion of classroom time for emergency management, pathophysiology and pharmacology. Resident evaluations of residency programs have found classroom fatigue to be an issue with the nurse residents (Keller et al., 2006). Pine & Tart (2007) reported that the residents would have preferred less formal instruction and more interactive, spontaneous learning experiences and additional team work experiences. Length of residency programs. The residencies varied in length from eight weeks (Owens et al., 2001) to 18 months (Halfer & Graf, 2006) but one year in length was most common (Altier & Krsek, 2006; Beecroft, et al., 2001; Pine & Tart, 2007). Truman (2004) described a six month residency, while Halfer (2007) described a variable residency based on the specialty area; medical/surgical was four months long, critical care and emergency department residencies were six months long, and the perioperative

25 16 area was nine months in length. Mills and Mullins (2008) described a residency that lasted three years. The main outcome of these residency programs was decreased turnover (Altier & Krsek, 2006; Beecroft et al., 2001; Cavanaugh & Huse, 2004; Owens et al., 2001; Strauss, 2009; Williams et al., 2007). Other outcomes included improved critical thinking (Messmer et al., 2004; Williams et al., 2007) and improved technical skills (Beecroft et al., 2001; Williams et al., 2007). Additionally, improvements were seen in clinical knowledge, confidence and feeling more comfortable in the role of the professional nurse (Messmer et al., 2004); interpersonal relationships (Williams et al., 2007); leadership abilities, time management, and awareness of professional opportunities (Halfer & Graf, 2006). Also reported were fewer errors, positive recruitment efforts (Cavanaugh & Huse, 2004), increased job satisfaction, and intent to remain (Grindel & Hagerstrom, 2009). Persaud (2008) reported that some of the mentees in their study are now mentors because of their experiences in their residency. Costs of residency program. Costs associated with the residency program include salaries of the nurses/residents, the preceptors, materials, refreshments, facilitator cost, the cost to replace the & nurses on the unit while they attend the program, and the cost of the residency program (Pine & Tart, 2007). The total cost of the program for 48 new nurse residents was $93,100 or a cost of $2, per new nurse resident. The salaries of the residents were not included in the costs calculations. The residency yielded a return on investment (ROI) of 84.7%, in contrast with the estimated $41,400 replacement cost of one nurse. The turnover rate of new RNs dropped from 50% in 2004 to 13% in

26 following the implementation of the residency program (Pine and Tart, 2007). Orsini (2005) reported a drop in attrition on one unit from 22.6% to 7.7%. Beecroft et al., (2001) also reported significant costs and benefits from an internship program. The total cost of the residency for 21 new RNs was $806, (including the salaries of the nurses/interns). The ROI of the internship was 67.3%. The replacement cost of one RN in this study varied from $40,000 to $100,000 which was defined as 75%-125% of an RN s annual salary. The turnover rate decreased from 46% to 13% after the residency was in place. One unanticipated benefit of the program was a decrease in recruitment costs because the hospital now attracts new graduate RNs due to the opportunity to participate in the formal residency. Summary Ample evidence exists that demonstrates the efficacy of a formal new RN residency. Studies have shown significant cost/benefits to the organization when this is in place. In addition, turnover rates of new RNs decline in institutions that require completion of a residency.

27 18 Chapter 3 Methodology This chapter includes a description of the design, setting and sample for the project and the methods and procedures for the study. This is followed by a discussion of the feasibility and protection of human subjects. Design This project was an evidence-based practice change consisting of the implementation and evaluation of a sixteen-week nurse residency program for new RNs. This was a single-group cohort study using a before-and-after design. Sample and Setting The sample included the new nurse graduates who were beginning their first professional nursing practice in June of 2009 and who chose to participate and sign an informed consent. During the interview process, all new graduate nurses were given a letter written by the investigator that described the residency and assured the graduate nurse that consent to be a research participant was strictly voluntary and if they should decline to participate or chose to drop out at any time during the study, there would be no adverse effects on their employment at the site of the study. The setting was a 770 bed not-for-profit hospital in the southeastern United States. This facility employs 750 RNs and typically hires 60 new nursing graduates per year. Their current turnover rate is 20% and is defined as any nurse who leaves the organization. Transfers within the organization are not considered turnover. The hospital

28 19 acknowledges spending two to four million dollars per year in recruitment and orientation activities. Procedures The sixteen week residency was designed to improve the nursing practice of new RNs. The goals of the residency were to: (a) facilitate the transition of new RN Residents to the role of the professional nurse; (b) enhance clinical judgment and clinical competence of the new RN residents; (c) enhance understanding of the role of evidencebased practice in improving patient outcomes; and (d) improve psychomotor skills. The residency included both clinical and classroom experiences. Residents had both a Mentor and a Preceptor to guide and support them through the residency. The hospital has approximately one hundred trained preceptors and each Resident was matched to one of the trained preceptors. Selection of Mentors Mentors were solicited from the organization through the use of the flyers and posters from a pool of approximately one hundred fifty nurses who had achieved the designation of stage four in the organization. Stage four nurses are at least Bachelor s prepared and often have graduate degrees in nursing and who meet other, hospital determined goals. The investigator met with interested RNs and explained the residency program with an emphasis on the unique role of the Mentor in the residency. Mentors were RNs who did not work on the same unit as the new RN and many did not work in a clinical role themselves. They were the objective listening ear for the new RN resident to go to for guidance and emotional support. Mentors also served as role models for the new RN resident. The ideal mentor was a Master s prepared RN for

29 20 whom nursing has been a fulfilling career. The Mentors all possessed good communication skills, had a passion for the profession, and the ability to maintain the confidentiality of the Resident. The two primary functions of the Mentors were to be available to the Resident in person, by phone, or online and a willingness to meet with and listen to the Resident, providing guidance and support, in an environment of nonjudgmental caring. Selection of Preceptors Preceptors were also solicited from the organization. Preceptors worked 1:1 with the Resident on a daily basis and oversaw the clinical portion of the residency, determined the specific learning needs of the Resident and guided them through the residency. The Preceptors served as role models for the Resident and were key to fostering an organizational climate that supported the Resident. The ideal Preceptor was a Bachelor s or Master s prepared RN who possessed good communication skills, enthusiasm about nursing, enjoy teaching and capable of being supportive of the Resident. Preceptors were RNs with at least three years clinical experience, and functioned at the competent or proficient level as judged by their nursing supervisors. Matching New RNs with Mentors and Preceptors The investigator then paired the Resident with both a Mentor and a Preceptor based on the unit to which the Resident was assigned as well as identified areas of interest and personal and professional experiences.

30 21 Preceptor/Mentor Orientation The investigator met with Residents, Preceptors, and Mentors as one group so each was familiar with the role of the other. This was a four-hour session during which a presentation on adult learning and specifics of the nurse residency program were given by the investigator. The Residents, Preceptors, and Mentors were given handouts outlining their roles in the residency, the goals of the residency, strategies to reach the goals, the schedule for the residency, dates and times for the weekly meetings, and contact information for the investigator (see Appendix C). Survey Tool Each Resident, Preceptor, and Mentor was provided with a survey at the beginning of the residency and the same survey at the end of the residency (see Appendix D). This tool sought to determine the perceptions of the participants on eighteen (18) areas of professional practice perceived to be areas of weakness in new graduate RNs based on the evidence found in the literature. The tool was developed by the primary investigator based on the review of the evidence that indicated key elements about which new nurses and/or their employers are concerned. The survey uses a 5 point Likert scale on each of the 18 topics. The topics included critical thinking skills, clinical judgment, clinical competence, able to utilize evidence in practice, possess conflict resolution and communication skills, adequate technical skills, able to delegate safely, prioritize care for a group of clients, manage time appropriately and prioritize care for a group of clients, identify and respond to emergencies, manage end of life issues, interpret lab and other diagnostics, able to practice autonomously, is able to function as a member of a team,

31 22 feels satisfied with their choice of a nursing career, intends to pursue higher education and sees the need to join a professional nursing organization. Curriculum The curriculum for the nurse residency program included both classroom and clinical components for a total of 40 hours per week. There was a total of 24 hours of classroom and 616 hours of clinical during the 16-week residency. Classroom Classroom activities consisted of 90 minute sessions over the 16-weeks of the residency (see Appendix E). The classroom instruction was initially be provided by the investigator, but was later taught by clinical experts from the organization who volunteered to speak on the scheduled topics that were of interest to them. The focus of these classroom sessions was educational, but they also provided a venue for the Residents to share experiences, decompress and bond with their fellow residents. Educational topics were based on the learning needs of the group. All Residents in attendance participated in areas identified in the evidence as areas of weakness such as exercises to improve clinical judgment in specific patient scenarios, safe delegation and prioritization. Diagnostic exams and their interpretation were discussed and improving communication skills received attention. Clinical Clinical activities took place on the assigned units, with Residents working sideby-side with their assigned Preceptor. Preceptors continually assessed the knowledge and competency of the Residents and worked with the investigator and the Mentor to develop Resident improved, the Preceptor played a more supervisory role.

32 23 Data Collection Before the residency began, all preceptors and mentors were asked to complete the New Nurse Survey. The Residents completed the New Nurse Survey to determine their self-perception of their level of competence on hire into the institution. The Preceptors and Mentors completed the New Nurse Survey to determine their perception of the skills and abilities of new graduate RNs in general. The information gained from the completed tools served both as a basis for individualized teaching and as baseline data on the knowledge and skill level of the individual nurse resident. At the end of the residency, the Residents again completed the New Nurse Survey, providing an evaluation of their own clinical skills, judgment and abilities. Residents and Mentors also completed the New Nurse Survey, this time answering specifically about the competencies of their Preceptee/Mentee. Each Resident had a unique identifier which was coded on all of the surveys. For example, if the nurse was 001, her/his pre-residency self-evaluation was coded 001-A; her/his post-residency survey was coded 001-B; her/his Preceptor s pre- post-residency survey was coded as 001-PA and 001-PB; and her/his Mentor s pre- post-residency surveys was coded as 001-MA and 001-MB. This allowed for analysis of data not only in the aggregate, but also to determine changes over time. Feasibility The only associated costs were in manpower and copying. The facility bore the cost of manpower, which was substantial. The hospital already utilized preceptors in their current orientation of new graduate nurses so this did not increase the workload on this group of nurses. The hospital has a clinical ladder and serving as a preceptor

33 24 provides the nurse another way to climb to the next step. Copying costs and time associated with interviewing and selecting preceptors/ mentors, teaching classes and overseeing the process was borne by the investigator. Now that the trial is completed, the full cost of the residency will be borne by the organization. Protection of Human Subjects Prior to the start of the project, permission was obtained from the Institutional Review Boards (IRB) of both the University of North Florida and the hospital where the residency took place. The potential subjects were informed that the hospital currently provides new nurse graduates with an orientation and the risks of involvement in this residency would be the same as any new graduate nurse who becomes employed at the hospital. Benefits included possible enhancement of clinical skills/judgment and acquisition of a professional nursing mentor.

34 25 Chapter 4: Results This chapter includes information on the sample characteristics of the new nurse residents, the preceptors and the mentors. This is followed by a description of before and after results of the nurse residency program on perceptions of competencies of new nurses. Sample Of 14 new nurses hired in the facility during the project, 10 (71.43%) completed the informed consent and initial data collection, but only 9 became participating Residents. The tenth new graduate nurse did not feel she needed the residency and never participated. The new nurse Residents were then matched with Preceptors from the unit where they were assigned. Mentors were assigned by the investigator, based on interviews and areas of common interest. By design, none of the Mentors were associated with the assigned units of the Residents and Preceptors. At the initial data collection there were ten (10) each; Residents, Preceptors, and Mentors. With the exception of age, the demographic characteristic of the Residents, Preceptors and Mentors were similar (see Table 4.1). Residents were significantly younger than the Preceptors and Mentors. With respect to educational preparation, the Residents and Preceptors were identical, while there were significantly more Mentors who held master s degrees. Experientially, the Mentors had worked in nursing significantly longer than the Preceptors (p <.05).

35 26 Table 4.1 Sample Characteristics (n=10) Characteristic Residents Preceptors Mentors Age (21 to 48) (25 to 57) (33 to 61) Gender Female Male Race Caucasian African-American Highest Educational Preparation Associate Degree in Nursing Bachelor s Degree in Nursing Master s Degree in Nursing Other Master s Degree 1 Years of Experience as an RN 0 to (2 to 37) (7 to 40) 1 One of the Mentors did not answer this question 2 One of the Residents had been an LPN for 12 years prior to attending nursing school Reliability of the Survey Instrument Cronbach s Alpha was utilized to determine internal consistency of the researcherdeveloped tool used for the competency survey. The Cronbach s Alpha for the survey in the pre-residency period was.847 for the Residents,.698 for the Preceptors,.890 for the Mentors, and.899 for all three groups combined. The Cronbach s Alpha for the survey in the post-residency period was higher, at.916 for the Residents,.940 for the Preceptors,.964 for the Mentors, and.953 for all 3 groups combined. Pre-Residency Survey Results The results of the pre-residency surveys are shown in Table 4.2, reflecting the preresidency beliefs of the Residents about their own clinical skills and abilities and the perceptions of the Preceptors and Mentors of the skills and abilities of new nurses in general. The Residents scored themselves higher overall than the Preceptors and Mentors

36 Table 4.2 Pre-Residency Perceived Competencies of New RNs by the Residents, Preceptors and Mentors Survey Item: I / New nurses 1 Mean Scores on a 1-5 Likert scale (higher = more agreement) Residents Preceptors Mentors have the critical thinking necessary for safe nursing practice have the clinical judgment necessary for safe nursing practice have the clinical competence necessary for safe nursing practice use evidence in daily nursing practice have adequate conflict resolution skills have adequate communication skills have adequate technical skills have the skills necessary to safely delegate have the skills necessary to prioritize care for a group of clients have the ability to manage time appropriately have the ability to identify and respond to emergencies are able to manage end of life issues have the ability to interpret lab and other diagnostics can participate in autonomous nursing practice are satisfied with career choice in professional nursing intend to pursue higher educational levels join professional nursing organization function as a member of a team Total Residents rated their own ability, Preceptors and Mentors rated their perception of the competency that new RNs in general possess 27